Two-Tier Hospital Care

Doctors and patients discuss the problem of inequality in medical care.

To the Editor: Re “Hospitals’ Red Blanket Problem,” by Shoa L. Clarke (Op-Ed, Oct. 26), about V.I.P. treatment for some patients who are wealthy or well connected:

We physicians are only human, so of course we are at risk for giving unequal treatment to patients who differ from one another in so many ways. Patients who are “nice” and more cooperative tend to get better treatment than difficult and hostile patients.

Patients we can’t relate to because of race, age, a language barrier or mental ability may all be treated in subtly different ways. Patients we “like” for a variety of reasons probably get better treatment. Even good-looking patients probably unwittingly inspire more attentive care.

And it is well known that physicians as patients may actually get lesser quality care from a colleague who is unable to remain objective.

As physicians we all need to be aware of this human flaw and follow the advice I was given 25 years ago when I asked my obstetrician if he was worried about being able to care for me, a physician who was also a patient. He said, “If you treat every patient as if she is royalty, then when the real Queen of England shows up, you won’t have any problem treating her.”

I have tried to remember this in every patient encounter since then.

PEGGY EURMAN

West Linn, Ore.

The writer is an internist.

To the Editor: Dr. Shoa L. Clarke’s article highlights some of the basic concerns shared by many physicians who take care of these “red blanket” patients (myself included). But he doesn’t go far enough in describing the different type of care given to these “important” patients. That care often includes far more than organic yogurt and granola for breakfast or a room with a view.

Hospitals often have liaisons who work to make sure that these patients get special treatment at the expense of others.

This includes expediting tests or procedures, and even making sure that a patient gets a private room on a non-amenity floor if the patient needs a particular service not available elsewhere. The liaisons are explicitly charged with prioritizing these privileged few at the expense of other patients, regardless of whether or not the special treatment is medically warranted.

As long as hospitals continue to act as for-profit institutions masquerading as nonprofit, we will continue to have a two-tier health care system where resources are diverted from those who need it most.

SURAFEL TSEGA

Brooklyn

The writer is a hospitalist.

To the Editor: There will always be people who feel the need for special treatment, whether it’s getting into a V.I.P. nightclub, flying first class, wearing obvious designer labels and so on. That’s how the world is.

But instead of focusing on why some people get special treatment, we should be asking why everybody isn’t getting treated as well as everybody deserves to be treated. In other words, instead of focusing on why some people get more, we should be focusing on why so many are getting less.

Why are some people not treated well because of their skin color? Why are some people left in a hospital room with no sunlight and facing a brick wall? Why are people given horrible food in hospitals? On planes, why are people in coach crammed in like cattle and made to wait in line for the bathroom when first-class bathrooms sit empty?

Everybody should be treated at the same highest level of care.

LYNN NEVINS

Astoria, Queens

To the Editor: A real danger of “red blanket” treatment is avoiding uncomfortable parts of the exam, especially for friends.

Late one Friday afternoon many years ago, my office manager asked me to examine her husband, “Fred,” for a cough. His own doctor was away, and an irritated office manager was not an attractive prospect. I agreed, but only if Fred were enrolled as an official patient with a medical record.

As with all new patients, I performed a complete history and exam, including a rectal that showed a drop of blood that he attributed to hemorrhoids. I said we were going to do an immediate sigmoidoscopy (I am a gastroenterologist).

The procedure was done in spite of my office manager’s protestations that Fred was there only for a cough. It revealed an early cancer as the source of bleeding. His surgery was curative. Being color-blind regarding blankets is good.

HERBERT RAKATANSKY

Providence, R.I.

The writer is clinical professor emeritus of medicine at the Warren Alpert Medical School of Brown University.

To the Editor: Having eloquently expressed his concern that patients identified as affluent will get better care in hospitals, Shoa L. Clarke also alludes to the troubling possibility that such practices threaten medicine in general. The introduction of “concierge service” for select patients in some medical offices certainly substantiates his anxiety.

My father, Dr. Hilliard Dubrow, practiced obstetrics and gynecology with distinction in New York City for half a century. His receptionist, not he, always discussed fees with patients because he never wanted them even to suspect that their ability to pay would influence the care they received from him.

And when conveying that information, the receptionist was instructed not to say “we have two fee scales, one lower than the other” but rather “our fee is X, but for young couples like you” — or retired people on a fixed income or whatever the situation — “we can reduce it to Y”; he believed that this formula would also avoid any implication that a secondary scale of fees might lead to second-class treatment.

The faint noise you hear in the background as you read this is Dad turning over in his grave.

HEATHER DUBROW

New York

To the Editor: The photograph accompanying the online version of the article shows a patient’s breakfast table laid with dishes of bacon, eggs and bread with butter and preserves. I hope that the patient for whom this spread was intended was not admitted for heart disease. If the disease doesn’t kill him, that diet certainly will!